Provider Demographics
NPI:1659858827
Name:JACK, DENNIS MICHAEL (FNP)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:MICHAEL
Last Name:JACK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6103 WOODFORD DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VIEW
Mailing Address - State:NY
Mailing Address - Zip Code:14085-9457
Mailing Address - Country:US
Mailing Address - Phone:716-609-0312
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-609-0312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343352363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily